Rehabilitation Approach of Children with Cerebral Palsy

1. Rehabilitation Approach of Children with Cerebral Palsy Presented by AmalAlShamlan Head of Rehabilitation Section AlWasl Hospital Dubai Health Authority AlWasl Hospital - Rehabilitation Section

2. outline • Definitions • Model of care • Classification • Outcome measures • Intervention strategies & philosophies AlWasl Hospital - Rehabilitation Section

3. What is Cerebral Palsy? It is a group of conditions results in permanent disorders of movement & posture due to damage in fetal or infant brain Features: 1.epilepsy.2. involuntary movement3. abnormal sensation & cognition4- abnormal vision , hearing & speech.5- mental retardation.6. abnormal movement / behaviour. AlWasl Hospital - Rehabilitation Section

4. What is Rehabilitation ? Rehabilitation is combined and coordinated use of medical , therapeutic , social , educational and vocational measures for training or retraining the individual to highest possible level of function • Holistic Approach • QOL AlWasl Hospital - Rehabilitation Section

5. Aims • Improve functional status • Prevent secondary impairments & functional limitations • Efficiently use resources when there is reasonable prognosis for improvement • Facilitate integration into the community AlWasl Hospital - Rehabilitation Section

6. Model of care • Functional & social vs disease-based • Growth & development • Child-focused & family centered. AlWasl Hospital - Rehabilitation Section

7. International Classification of Functioning, disability and Health (ICF) condition Body Function & structure Activities Participation Environmental Factors Personal Factors World Health Organization , 2001 AlWasl Hospital - Rehabilitation Section

8. International Classification of Functioning, disability and Health (ICF) C.P. Activity Limitation Walking on slopes Walking in crowds Climbing on equipment Impairments Muscle weakness Muscle hypoextensibility Poor balance Poor endurance Participation Walking to class room Play during recess P.E class Environmental Factors Teachers’ concern Distance to play ground Children crowded in equipment Personal Factors Child’s attitude toward: being transported Adult assistance AlWasl Hospital - Rehabilitation Section

9. Multidisciplinary Team AlWasl Hospital - Rehabilitation Section

10. Care Pathway AlWasl Hospital - Rehabilitation Section

11. Interdisciplinary Approach • Working for common goals • Pooling of expertise • Opportunity for personal growth & development • Forum for problem solving AlWasl Hospital - Rehabilitation Section

12. Classification of CP • Etiology • Body involvement • Movement disorder impairment AlWasl Hospital - Rehabilitation Section

13. GMFCS for children with CP AlWasl Hospital - Rehabilitation Section

14. Outcome measures • Validate progress • Provides accountability to child/family/third-party payers for intervention used • Aides in plan of care • Provides normative data to obtain developmental levels e.g. age equivalent , standard score AlWasl Hospital - Rehabilitation Section

15. Tests Measuring Developmental Age , Activity , or participation Abilities AlWasl Hospital - Rehabilitation Section

16. Assesses normative performance of gross/fine motor function for children from birth to 72 months of age Assess gross motor function including maturation of skills and postural alignment of of infants from birth to 18 mths of age Assess postural control & alignment needed for age appropriate functional activities in early infancy 34 wks gestational age to 4 mths post full term delivery date PDMS AIMS TIMP Used to evaluate quality of UE functions in 4 domains: dissociated movement, grasping, protective extension & weight bearing Assessment of motor tone & oromotor function for preterm babies More than 33 wks corrected age – 1 mths post term Specifically designed for CP , developed to measure change over time . Consists of activities in 5 dimensions: lying & rolling, sitting, creeping & kneeling, standing & walking, running & jumping. LAPI QUEST GMFM

17. communication rating scale AlWasl Hospital - Rehabilitation Section

18. Spasticity • Spasticity is one of the most common UMN lesion problem seen in children with CP resulting in postural control & movement disorder thereby limitting, delaying or arresting the sensory motor development.(also other areas like communication, cognition, social , perception etc). AlWasl Hospital - Rehabilitation Section

19. What is spasticity? Spasticity is amotor disordercharacterized by a velocity dependent increase in stretch reflexes(muscle tone) with exaggerated tendon jerks resulting from hyper excitability of the stretch reflex as one component of the UMN syndrome (Lance, 1980). Spasticity is amovement disorderaffecting both the neural & non-neural characteristics of postural tone and can be described by the positive & negative UMN symptoms” (D. Burke, 1988). AlWasl Hospital - Rehabilitation Section

20. Neural components of UMN symptoms Positive symptoms • Spasticity. • Spasms (flexor & extensor). • Exaggerated tendon reflexes. • Clonus. • Babinski response. Negative symptoms • Weakness. • Loss of dexterity. • Fatigability. AlWasl Hospital - Rehabilitation Section

21. Non-neural component of UMN symptoms • Altered muscle length (elasticity): muscle fibres shorten (hypoextensible). • Altered muscle structure (viscosity): filaments become sticky affecting muscle glide(stiffness). • Abnormal co- contraction (reciprocal innervation) : due to bio- mechanical effects of abnormal position. (too much stability & not enough mobility). Changes in visco-elastic properties leads to stiffness, tightness & contracture. AlWasl Hospital - Rehabilitation Section

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23. CP? AlWasl Hospital - Rehabilitation Section

24. Intervention Philosophies & strategies Evidence based? There is no evidence that any one treatment method is superior to another. Therapists select from the variety of treatmentsavailable those that best meet the child’s and family’s need. AlWasl Hospital - Rehabilitation Section

25. Analyzing • Analysing the postural tone & patterns of movement. • What the child can do? How? /can’t do ? why? • Choosing appropriate intervention/frequency depends on: • Age (infant, toddlers, preschool, adolescent etc) • Distribution of postural tone (diplegic, hemiplegic, quadriplegic etc) • Quality of postural tone (mild, moderate or severe). • Associated problems.(vision, hearing, cognitive, seizure, SPD etc) AlWasl Hospital - Rehabilitation Section

26. Early intervention Studies focused on child and family reported favorable outcomes. The analysis also suggested that parent participation might have a greater impact on child’s outcomes for children younger than 3 yrs. AlWasl Hospital - Rehabilitation Section

27. Neonatal Developmental screening • Neonatal physiotherapy is an advanced practice subspecialty area of paediatric physiotherapy and involves a highly complex set of skills in observation, examination and intervention procedures for the extremely fragile NICU population. • Main objective to identify developmental delay in 1st year of life • Early intervention can change abnormal movement pattern in mild to moderate cerebral palsy • Those whom deemed to be delay remain delay if no intervention started. AlWasl Hospital - Rehabilitation Section

28. All high risk preterm infants with meeting criteria: • Gestation 32 weeks and below • Birth weight < 1.5 kg • IVH GR.3&4, PVL • Chronic lung disease or O2 dependency • Ventilated for RSD AlWasl Hospital - Rehabilitation Section

29. Neonatal Developmental screening • NICU : LAPI • Outpatient : TIMP , AIMS , PDMS • 2008 37 - 11 detected • 2009 57 - 17 detected AlWasl Hospital - Rehabilitation Section

30. Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit AlWasl Hospital - Rehabilitation Section

31. Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit AlWasl Hospital - Rehabilitation Section

32. Intervention Philosophies & strategies Neurodevelopmental Therapy ( NDT) Moving through normal movement patterns to experience normal movement Major components : reflex-inhibiting posture, inhibition of abnormal reflexes, normalization of muscle tone, and adherence to normal developmental sequence of motor progression AlWasl Hospital - Rehabilitation Section

33. NDT • Inhibiting abnormal movement patterns. • Facilitating normal movement patterns. No strong evidence that supports the effectiveness of NDT for children with CP with respect to normalizing muscle tone , increasing rate of attaining motor skills, and improving functional motor skills Butler C, Darrah J: Effects of Neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence report. Dev Med Child Neurol 2001 ; 43: 778 - 790 AlWasl Hospital - Rehabilitation Section

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35. Intervention Philosophies & strategies Sensory Integration Therapy Principle:a neurobiological process organizes sensation from one’s own body and from environment and makes it possible to use the body effectively within environment Emphasis on importance of three body centered sensory systems : tactile , proprioceptive & vestibular AlWasl Hospital - Rehabilitation Section

36. SI Therapy AlWasl Hospital - Rehabilitation Section

37. Intervention Philosophies & strategies Constrained - Induced Movement Therapy • Constraining non-affected arm to encourage performance of therapeutic task with the affected arm, which children normally tend to disregard. • Systematic review has found the effectiveness of CIMT for children with hemiplegic CP. AlWasl Hospital - Rehabilitation Section

38. Serial casting Serial casting may serve to reduce spasticityin muscles by decreasing the strength of abnormally strong tonic foot reflexes.(Bertoli 1996). Serial casting in the CP population has been shown to improve ROM.( Brouwer 2000) Casting provides stability and prolonged stretch of a muscle which is immobilized in a lengthened position(Mosley 1997). At least 6 hrs of prolonged stretch is needed for effectiveness(Tardieu 1987). AlWasl Hospital - Rehabilitation Section

39. Botox + serial casting Botox reduces spasticity and improves ambulatory status.(Flett 1999) When used in combination with serial casting it has shown to help maintain and improve muscle length and passive ROM.(Kay 2004) Without conservative interventions such as serial casting, (with & without botox injection) more expensive procedures may be necessary. (Flett 1999) AlWasl Hospital - Rehabilitation Section

40. Intervention Philosophies & strategies Body Weight Supported Treadmill Training Uses theories of motor learning & importance of early task –specific training Theory : activate spinal & supraspinal pattern generators for gait AlWasl Hospital - Rehabilitation Section

41. Intervention Philosophies & strategies Strengthening Progressive resisted exercise improves muscle performance & functional outcomes in CP children Research had supported effectiveness on increasing force production in CP Dodd et.al. systematic review of strengthening for individuals with cerebral palsy . Arch Phys Med Reh,83:1157-1164, 2002 AlWasl Hospital - Rehabilitation Section

42. Intervention Philosophies & strategies NMES Multiple studies have demonstrated the effectiveness of NMES, • Reduce spasticity. • Increase ROM & strength. • Increase force production. • Promote initial learning of selective motor control. AlWasl Hospital - Rehabilitation Section

43. Intervention Philosophies & strategies Orthotic devices , splints , cast Goals : • Maintenance or increase ROM • Protection or stabilization of a joint • Promotion of joint alignment • Promotion of function AlWasl Hospital - Rehabilitation Section

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45. Ankle Foot Orthosis Compared with barefoot gait, AFO’s enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature PF and improved progression of foot contact during stance. AlWasl Hospital - Rehabilitation Section

46. Intervention Philosophies & strategies Assistive Technology & Adaptive Equipment • Optimizes alignment, posture & function. • Inhibits spasticity patterns. • Facilitates more normal movement.

47. Adjunct therapies • Hippotherapy. • Aquathearpy. • suits. • Theratogs. AlWasl Hospital - Rehabilitation Section

48. Intervention Philosophies & strategies Speech & Language Therapy • Oralmotor function using strengthening / Intraoral stimulation • verbal ( PROMPT) & non-verbal communication skills ( AAC & PECS , macatone) • auditory training for HI • audiometry screening • swallowing function AlWasl Hospital - Rehabilitation Section

49. Intervention Philosophies & strategies Psychological Assessment & Management Social support AlWasl Hospital - Rehabilitation Section

50. Out of 32 patients received botox 69% attended PT & 31% did not attend AlWasl Hospital - Rehabilitation Section